1. Clinician Job Application

Full Name*

First NameLast Name

Phone Number*

###-###-####

Email Address*

example@example.com

Which clinician position are you applying for?*

How did you hear about us?*

If offered a position, how much time will you need before you can start? Or when would be your ideal start date?*

(Please read this question carefully to determine if you are eligible) This is a full-time position. Full time clinicians maintain a minimum of 24 hours available to clients per week, with a minimum average weekly client caseload of 15 clients/week. Are you available for a full time position?*

YesNo

Our practice offers in-person and virtual sessions. Are you available to see clients in-person?*

YesNo

Many clients need to be seen in the evening hours or weekends to accommodate work and school schedules. Are you available to work some evenings / weekends?*

YesNoMaybe

Summit's Edge is committed to offering a flexible, yet set schedule for all employees. Are there any days of the week, or times of the day that you are NOT available?*

What year did you graduate from Graduate School?*

What is your License type and License number? (If not eligible for full licensure yet, please provide your projected date of eligibility for licensure)*

Has your license ever been suspended or revoked? If yes, please provide detailed explanation of what occurred and what was learned.

Provide your current clinical supervisor's contact information and number of supervision hours to date if applicable. (If fully licensed, write N/A)*

Please outline your past relevant work experience.*

Summit’s Edge is an Anti-Racist, Neuro-Diverse, Trans-Inclusive, LGTBTQ+, and Gender, Sexual, & Romantic Minorities-Affirming practice.

We are passionate about ensuring our organization is a safe space for our employees and our clients. As such, bigotry or any form of discrimination directed at our staff or other clients will not be tolerated and will result in immediate clinical termination.

Please provide your experience in working with marginalized populations below. If you do not have experience in working with marginalized populations, would you be willing to take on development opportunities for this competency prior to your start date, as well as after you've been hired?*

Please outline relevant specialty trainings and/or certifications you have received.*

Are there specialty trainings or certifications you plan to receive or are interested in obtaining in the next 12-24 months?*

Have you completed the required 6 CE's for providing tele-health services? If yes, can you provide proof of this?*

YesNoNo, but intend to

Have you ever been credentialed with an insurance panel before? If so, what insurance companies?*

Please list three references with email and contact information. *References are required in order to be considered. They will not be contacted until the final stage of the interview process**

Please Upload Your Resume*

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Please Your Cover Letter

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